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An Insight Into Pericoronitis REVIEW ARTICLE Dhonge RP et al: An Insight Into Pericoronitis REVIEW ARTICLE An Insight into Pericoronitis Roshan P. Dhonge1, R. M. Zade2, V. Gopinath3, Ramesh Amirisetty4 1- Post Graduate Student, Department of Periodontology, Chhattisgarh Dental College And Research Institute, Rajnandgaon, Chhattisgarh (India). 2- Professor, HOD and Dean, Department of Periodontology, Chhattisgarh Dental College And Research Correspondence to: Institute, Rajnandgaon, Chhattisgarh (India). 3- Professor, Department of Dr. Roshan P. Dhonge, 10, Ganesh Vihar No. I, Near Periodontology, Chhattisgarh Dental College And Research Institute, Rajnandgaon, Swastik Nagar and Water Tank, Amravati, Maharashtra, Chhattisgarh (India). 4- Reader, Department of Periodontology, Chhattisgarh Dental India. College And Research Institute, Rajnandgaon, Chhattisgarh (India). ABSTRACT Pericoronitis is inflammation of the soft tissue associated with the crown of a partially erupted tooth. It is seen most commonly in relation to the mandibular third molar. The common symptoms and signs are pain, swelling, trismus, halitosis, bad taste, inflammation of pericoronal flap and pus discharge from underneath it, inflammation sometimes aggravated by trauma from an antagonist tooth. In severe episodes, an acute pericoronal abscess may develop which may remain localized or spread to involve one or more of the adjacent deep surgical spaces and may be associated with systemic as well as local signs and symptoms. The treatment for acute phase include debridement of plaque and food debris, drainage of pus, irrigation with sterile saline, chlorhexidine or hydrogen peroxide, elimination of occlusal trauma and prophylactic antibiotic along with analgesics. The treatment planning for surgical intervention will be made after acute phase subsided. An extraction of partially or completely impacted third molar should be done. If the decision has taken to retain the tooth, in such circumstances removal of pericoronal flap can be done. KEYWORDS: Pericoronitis, Operculum, Wisdom tooth, Operculectomy AINTRODUCTIONA ranked as first or second. 3,4 It is most commonly seen in teens and young adults. The highest incidence was found Pericoronitis refers to inflammation of the soft tissue in in the 20-29 year age group and rarely seen before 20 or relation to the crown of an incompletely erupted tooth, 5 1,2 after 40. There was no significant difference found including the gingiva and the dental follicle. The word between the sexes. A seasonal variation was seen with the pericoronitis comes from the Greek word, peri means peak incidences during the month of June and December. "around", Latin word, corona means "crown" and itis Pericoronitis mostly seen with involved tooth in 67% of means "inflammation." It is also known as operculitis. vertical impacted cases, in 12% of mesio-angular cases, The soft tissue covering over a partially erupted tooth is in 14% of distoangular cases and in 7% of various other known as pericoronal flap or gingival operculum. positions. A significant correlation between oral hygiene Maintenance of oral hygiene in such area is very difficult status of individual and the severity of the condition is to achieve by normal methods of oral hygiene (Figure 1). present. Bilateral pericoronitis is a rare condition. It may be suggestive of underlying infectious mononucleosis.6 ACLASSIFICATION According to the International Classification of Diseases, pericoronitis can be classified as an acute and chronic pericoronitis. a. Acute : Acute pericoronitis is of sudden onset, short lived but having significant symptoms, such as varying degrees of inflammatory involvement of the pericoronal flap. There is also a presence of systemic involvement. Usually, the acute form of pericoronitis is seen in the patients having moderate or poor oral hygiene.6 b. Chronic : Fig 1: Pericoronitis in relation with 48 A Pericoronitis may also be classified as a chronic or It is most commonly seen in relation to the third molar, recurrent. In this category, repeated episodes of acute also called as wisdom tooth, particularly of mandibular pericoronitis occur periodically. It may cause few arch, but it can occur around the base of any tooth that symptoms, but some signs are visible at the time of has not erupted completely. Amongst acute oral health intraoral examination. The chronic type mostly seen with problems of young adults, pericoronitis is found to be good or moderate oral hygiene.6 How to cite this article: Dhonge RP, Zade RM, Gopinath V, Amirisetty R . An Insight into Pericoronitis. Int J Dent Med Res 2015;1(6):172-175. Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6 172 Dhonge RP et al: An Insight Into Pericoronitis REVIEW ARTICLE indentations of the cusps of the upper teeth or ulceration RISK FACTORS FOR may be seen. Systemic complications can occur such as fever, leukocytosis (increase in number of W.B.C.), PERICORONITIS malaise, regional lymphadenopathy and loss of appetite. Presence of unerupted / partially erupted tooth / teeth In severe cases, infection may extend in to the adjacent in communication with the oral cavity. Mandibular tissue spaces.1 third molars (which are placed vertical and distoangular) are most commonly affected. Chronic pericoronitis is characterized by a dull pain with Presence of periodontal pocket adjacent to unerupted mild discomfort lasts for a day or two, with remission / partially erupted teeth. lasting for many months. An area of ulceration may be associated with chronic pericoronitis may resembles Opposing tooth / teeth in relation to pericoronal necrotizing ulcerative gingivitis. Patient may also tissues surrounding unerupted / partially erupted tooth / teeth. complain of a bad taste. Pregnancy and fatigue are associated with an increased occurrence of pericoronitis.6 Previous history of pericoronitis. The radiographic appearance of the local bone can Poor oral hygiene status of individual. become more radiopaque in chronic pericoronitis. Respiratory tract infections and tonsillitis.7 MICROBIAL FLORA ETIOPATHOLOGY At the time of tooth development, as the dental follicle The most common site of pericoronitis is impacted or communicates with the oral cavity, it is said that bacterial partially erupted mandibular third molar. The most colonization occurs into the follicular space leading to common cause behind pericoronal inflammation is the initiation of infection.6,7 A bacterial species which are entrapment of plaque and food debris between crown of predominant in pericoronitis of erupting mandibular third tooth and overlying gingival flap or operculum. This is an molars are Streptococcus, Actinomyces and ideal area for the growth of bacteria and it is difficult to Propionibacterium species. Along with these, there is also keep clean. There are presences of constant chances of an evidence of presence of β-lactamase producing acute inflammation of pericoronal sites. It may be due to bacteria such as Prevotella, Bacteroides, Fusobacterium, aggravating factors such as trauma, occlusion or Capnocytophaga and Staphylococcus sp.8,9 It is proven entrapment of foreign body below the pericoronal flap. that the microbial flora of pericoronitis are predominantly Pericoronitis may leads to release of inflammatory tissue anaerobic.10,11 Pericoronal flap colonizes the same fluid and cellular exudate. It further increases the bulk of bacterial species which are seen in tonsillitis and the pericoronal flap leading to interference with complete periodontitis.12,13 Leung et al found that microbiota of closure of jaw. In this way, the process of pericoronal pericoronitis resembles that of gingivitis, periodontitis inflammation potentiated by occlusal trauma of the and detected P. gingivalis in 100% of the samples.14 pericoronal tissues by the opposing tooth. Chronic Rajasuo et al detected P. gingivalis in 9.1% of the inflammation and infection of operculum is present even samples12 while Mombelli et al found in 20% of healthy if patient is not having any signs or symptoms. On inner third molar pericoronal pockets.11 A. surface of operculum, there is presence of varying 1,6 actinomycetemcomitans detected in pericoronal pockets degrees of ulceration. A systemic conditions such as found to be: 17-40% by Mombeli et al, 9.1% by Rajasuo influenza, upper respiratory tract infections or a period of et al and 10.8% by Peltroche-Llacsahuanga et al stress may lead to compromised host immune system. So, respectively.11,12,15 T. forsythia also detected in acute pericoronitis can be considered as an opportunistic pericoronitis samples. It is difficult to isolate periodontal infection or may be an opportunistic exacerbation of a pathogens by microbial culturing from the pericoronitis chronic process which is normally kept in check by a sites. So, Polymerase chain reaction (PCR) has been competent immune system. shown to be a highly specific and sensitive test for 16 CLINICAL FEATURES detection of periodontopathogens in pericoronal flap. a Acute pericoronitis is characterized by a red, swollen, HISTOLOGICAL FEATURES suppurating lesion which is tender, with severe throbbing pain radiating to the ear, throat, floor of the mouth, There is an evidence of presence of hyperplastic temporomandibular joint and posterior submandibular epithelial lining of pericoronal flap along with region. There may also be a pain while biting. intercellular edema and infiltration of leukocytes. While Sometimes, pain may disturb sleep. A persistent connective tissue which is present underneath epithelium impaction of
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